Employment Application
Cummins Location: Today's Date: Reviewed By: Date available to start work:
Print name in full: LAST FIRST MIDDLE Social Security No.: Salary expected:
Present address: City: State & Zip Code:
Previous addresses over the past 10 years: Email address: Phone No. & Area Code:
Position applying for: Can you furnish proof of age? Cell Phone No. & Area Code:
HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE IN THE PAST SEVEN YEARS? ___ YES ___ NO.
EXPLAIN (USE THE BACK OF SHEET IF NECESSARY). YOUR ANSWER IS LOOKED UPON AS ONLY ONE OF THE FACTORS CONSIDERED IN THE EMPLOYMENT DECISION AND IS EVALUATED IN
TERMS OF THE NATURE, SEVERITY, AND THE DATE OF THE OFFENSE. LIST ONLY CONVICTIONS WHERE THERE HAS BEEN A DISPOSITION GIVEN BY THE COURT OR ANY OPEN / PENDING
CASES. CONVICTIONS FOR MARIJUANA POSSESSION UNDER 1 GRAM EXCEEDING 2 YEARS NEED NOT BE REPORTED.
Date(s) of Conviction(s) / Where?
List other names you have been known by over the past 10 years: Have you previously been employed by an affiliate or us? If yes,
who?
Do you have a current driver's medical certificate?: ____ YES ____ NO Drivers License Number & State:
Expiration Date:
This job may require a valid drivers license. List your license Class _____. Does your license require a physical? _____. License Expires:_______________.
List any endorsements on your license:
EDUCATION DATA
LEVEL NAME & LOCATION (CITY/STATE) COURSE OR MAJOR YEAR GRADUATED
HIGH SCHOOL: Graduated - list only
Yes ____ or No ____
COLLEGE:
TRADE:
OTHER:
Are you legally permitted to work in this Country? Yes ___ No ____ Is DMV print out submitted;
If no, why? (May be required) Yes ____ No ____
Do you have any job accomplishment of which you are particularly proud? Explain in detail.
List 2 Professional references by name & phone number:
1. 2.
Are you currently employed? May we contact your present employer before hiring? May we contact you at your present employer?
___ yes ___ no ___ yes ___ no ___ yes ___ no ___ yes, but carefully.
Do you intend to submit a resume as part of your application? ____ Yes ____ No.
If yes, initial your acceptance of the terms and conditions of this application form being applied to the information contained in your resume. _____________.
The fact that you have filled out this application will be kept strictly confidential and will not in any way be brought to the attention of your present employer without
your permission. Please give an accurate, detailed and complete record of your employment. Make sure that you list the full name of the person to whom you reported
and the phone number for each employer. Begin with your present position (please go to next page).
1903-00-060411-Cummins Application Form with new logo.doc
PLEASE LIST ALL JOBS HELD FOR THE PAST TEN (10) YEARS. USE BACK OF SHEETS TO LIST ADDITIONAL INFORMATION.
MOST RECENT EMPLOYER: Supervisors name & title:
May we contact this supervisor? YES NO
Street address: Phone number & area code:
City: State: Zip: Your job title:
Your job title & description: From (M/YR):
To:
-------------------------------
Salary:
Reason for leaving: Describe one major job accomplishment:
EMPLOYER #2: Supervisors name & title:
May we contact this supervisor? YES NO
Street address: Phone number & area code:
City: State: Zip: Your job title:
Your job title & description: From (M/YR):
To:
-------------------------------
Salary:
Reason for leaving: Describe one major job accomplishment:
EMPLOYER #3: Supervisors name & title:
May we contact this supervisor? YES NO
Street address: Phone number & area code:
City: State: Zip: Your job title:
Your job title & description: From (M/YR):
To:
-------------------------------
Salary:
Reason for leaving: Describe one major job accomplishment:
PERIODS OF UNEMPLOYMENT: (describe each period of unemployment in excess of 30 days for the past 10 years)
From To Reason
______________________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY: THEY CONSTITUTE THE CONDITIONS UNDER WHICH YOU MAY BE EMPLOYED.
The information that I have provided herein is accurate to the best of my knowledge. I hereby authorize the Company and/or its agents to investigate my background
and to verify any and all information of concern to my records, whether such information if favorable or unfavorable to me. I understand that any material
misrepresentation or deliberate omission of a fact in my application may be justification for refusal of employment, or if employed, termination from the Company. I
acknowledge that any copy of this document carries the full force of the original document for legal purposes. I do hereby agree to forever release and discharge the
Company, their agents, and their associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs, and expenses, or any other charge or
complaint filed with any agency arising from the retrieving and reporting of information. By checking here _____ I do request a copy of my consumer report if that
report is made part of this investigation of me.
I hereby acknowledge than any employment relationship with Cummins West, Inc. is of an "at will" nature, which means that an Employee may resign at any time and
Cummins West, Inc. may discharge an Employee at any time with or without cause, and with or without notice. This "at will" employment rela tionship may not be changed
by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of Cummins West, Inc. For an Employee
covered by a collective Bargaining Agreement, applicable discharge provisions of that agreement shall govern.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I
am required to abide by all rules and regulations of Cummins West, Inc.
I agree and understand that any offer of employment will be conditional on my successful completion of a pre-employment physical examination and drug screening
test. Also, if hired, I understand that as part of company policy, I agree to a drug screen test if I required medical attention from a physician due to a work related
injury.
Date: _____________________ Applicant's Signature: _____________________________________________________
1903-00-060411-Cummins Application Form with new logo.doc
SKILLS
(1) To be completed by Service/Technical Applicants
TRUCK AND ENGINE EQUIPMENT
Area Formal Years of Area Formal Years of
Training Experience Training Experience
(Check) (Check)
Drive Line Components Electrical Repair
Diesel Engine Tune-up & Rebuild Frame and Wheel Alignment
Gas Engine Tune-Up and Rebuild Brakes
Tire Service Cooling System
Trailer Repair Inspections
Air Conditioning General Car Repair
SHOP EQUIPMENT
Area Formal Years of Area Formal Years of
Training Experience Training Experience
(Check) (Check)
Electrical Diagnostic Equipment Air Conditioning
Sheet Metal Equipment Wheel/Tire Balance Machine
Frame & Axle Straightening Engine Dynamometer
Equip.
Engine Rebuilding Equipment Chassis Dynamometer
Diesel Injection Equipment Engine Analyzer
Electric Welder Inspections
Oxyacetylene Welder Noise Measuring Equipment
Paint Spray Gun Smoke Measuring Equipment
(2) To be completed for Office/Administrative & Supervisory Positions:
ADMIN/OFFICE SKILLS
Area Formal Years of Area Formal Years of
Training Experience Training Experience
(Check) (Check)
Computer Data Entry Computer Programs:
Typing (WPM ________) MS Word
Accounts Payable & Receivable MS Excel
Supervisory Experience MS Access
Office Equipment: MS Powerpoint
Computer Quickbooks
Type of computer:
________________________ Version: _________
Fax Machine Email
Photocopy Machine Internet Use
Other Skills: (please list) Other Computer Programs: (please list)
1903-00-080903-Cummins Application Form.doc
THIS SECTION TO BE COMPLETED BY CUMMINS WEST, INC. ONLY
EMPLOYMENT CHECK-OFF LIST
REFERRED BY/AGENCY _____________________________________________________________________
POSITION APPLYING FOR: __________________________________ BRANCH _______________________
RESUME ATTACHED: ________YES ________ NO
BACKGROUND CHECK FAXED ON: ___/___/___ TIME: _______
BACKGROUND CHECK RETURNED ON: ___/___/___
PHYSICAL COMPLETED ON: ___/___/___ DRUG TEST COMPLETED: ___/___/___
INTERVIEW DATE: ___/___/___ INTERVIEW TIME: ________
INTERVIEW BY: ___________________________________________________________________________
HIRE APPROVAL(S): _______________________________________________________________________
START DATE: ___/___/___ SALARY: ___________
COMMENTS
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
1903-00-060411-Cummins Application Form with new logo.doc
Affirmative Action Self ID Survey
Applicants and employees are treated without regard to race, color, religion, sexual orientation, gender, national origin, citizenship status (unless
required by a government contract), age, marital or veteran status, physical or mental disability, or any other legally protected status during every
aspect of the employment process.
As employers and government contractors, we comply with government regulations and affirmative action responsibilities. Solely to help us comply
with affirmative action record keeping, reporting and other legal requirements, please complete the survey below. This information will not be used
for hiring, placement, or other decisions related to the terms and conditions of employment. This document will be kept in a confidential file, separate
from applicant and personnel files. When reported, data will not identify any specific individual.
YOUR COOPERATION IS VOLUNTARY
INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION
Please complete the following information. Please print.
Last Name: First Name:
Date: Job Title/Req Number:
Gender
Male Female
Ethnicity - Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin,
regardless of race.)
Yes No
Race - If you are not Hispanic or Latino, please select the appropriate race category.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
Black or African American (Not Hispanic or Latino) A person having origins in any of the Black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,
Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and
South America (including Central America), and who maintains tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) - persons who identify with more than one of the above five races.
I respectfully decline completing the information being requested above. ________ initials
EEO/AA/MFDV Employer
1903-00-060411-Cummins Application Form with new logo.doc

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